Original Article

Radiographic Diagonsis of Jaw Sarcomas

Part II Angiographie Features of Osteosareoma

and Fibrosareoma of the Mandible

Gang ZHANG, D.D.S., M.S., Xu-chen MA, D.D.S., Ph.D.

and Zhao-ju ZOU, D.D.S., F.I.C.D.

Department of OraI Radiology, School of Stomatology, Beijing Medical University, Beijing, China

(Received : Sept. 25, 1989, Accepted : May 12, 1990)

Key Words : Osteosarcoma, Fibrosarcoma, Angiography, Speciment

Based on preoperative angiography of three cases of jaw sarcomas and arteriography of their

specimens, it has been noticed that the supplying arteries of the mandible ramus sarcoma can be

directely from the external carotid arteries; and the supplying arteries can be from inferior alveolar

artery in the sarcomas of the body of mandible. The tumors were more vascularized than the surround-

ing normal tissues, and the direction of the arteries can be from central to peripherial in the tumors,

which were different from the long bone sarcomas.

The vascularization and the retarded blood flow in the tumor are the significant anatomic bases for

local perfusion chemotherapy of jaw sarcomas.

Angiographic features of osteosarcoma

and fibrosarcoma of long bones have been

described by many authors ~-5). However, it

is very rare to describe the angiographic

features of jaw sarcomas. Digital subtrac-

tion angiorgraphy of three cases with jaw

sarcoma and arteriography of their speci-

ments were performed in the present study.

M a t e r i a l s a n d M e t h o d s

Three cases with jaw sarcomas are in-

Oral Radiol. Vol.6 No.1 1990(9~14)

cluded in the present study. Two of them

were osteosarcoams of the mandible and the

other was fibrosarcoma of the mandible.

The age of the cases was 15, 19 and 31 years

respectively. All of the were males.

1. Digital subtraction angiography of the

external carotid artery was performed for all

three cases before the operation. Seldinger's

method of catheterization was used. The

catheter was eventully introduced into the

external carotid artery. The 1,000mA

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Polydose 80 Angitron CMP digital subtrac-

tion angiographic unit made by Simens was

utilized.

1A. Intra-arterial digital subtraction angiograph (IA-DSA). Lateral projection showed displace- ment of the external carotid artery(t) and that the main supplying artery of the tumor was directly derived from the external carotid artery (O).

2. Plain radiographs were taken of all the

three speciments after surgery.

3. Arteriography of the speciments infusing

red lead oil from the main supplying artery of

the tumor was performed within four hours

after the operation of the three specimens.

Physiological saline solution was infused

through the main supplying artery of the

tumor before infusion of red lead oil. About

100 mmHg injection pressure should be kept

during the infusion of red oil. When the red

oil extravasated from the marrow of the

anterior edge of the specimen, the infused

artery was ligated and then the specimen was

laid aside undisturbed for twenty minutes.

Radiographs were taken of every specimen.

The projection position and exposure condi-

tions were the same as for the plain radio-

graphs. All of the three specimens were

fixed with 10% formalin, decalcified and then

embeded in paraffin wax. Sections measur-

ing 4-6 microns were stained with haematox-

ylin and eosin and examined by light micro-

lB. IA-DSA. Anterio-posterior projection showed 1C. IA-DSA. Lateral projection. Venous phase tumor stain and tumorous vessels encompass- showed that staining time of the tumor was ing the tumor (O). much longer than the durrounding normal

tissues ( } ).

Fig. 1 (A, B, C) The case with osteosarcoma of the mandibular ramus.

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scopy.

Resul t s

1. Angiographic findings before surgery

A. Displacement of the ex te rna l carot id

ar te ry

Displacement of the ex te rna l carot id

ar te ry was seen in all three cases due to the

pressure of the growing tumor(Fig. 1A).

There was no evidence of the externa l ca-

rotid a r te ry being invaded.

B. Main supplying ar ter ies of the tumor

The main supplying ar te ry of the tumor

was the inferior a lveolar a r te ry in two cases

with the t u m o r loca ted in the m a n d i b u l a r

molar r e g i o n (Fig. 2A) and was directly de-

2A IA-DSA. Lateral projection showed that the main supplying artery of the tumor was the inferior alveolar artery and that irregularly narrowing and dilatation of the supplying arteries (t)) and small blood lakes could be seen'(} ).

2B Pathological section showed that the inferior 2C Pathological section showed that abundant alveolar artery lost its normal configuration vessels with an extremely thin vessel wall and became a dilated pathological vessel with between the sunburst tumorous bone in the an extremely thin vessel wall (H.E., soft mass of the tumor could be seen (H.E., Magnification, x 12) (t) . Magnification, x 60) ( "t ).

Fig. 2 (A, B, C) The case with osteosarcoma of the mandibular morlar region.

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rived from the external carotid ar tery in

another case with the tumor located in the

mandibular ramus (Fig. 1A). The supplying

arteries were enlarged and irregularly narr-

owing and dilating in the tumor (Fig. 2A).

C:. Staining of the tumor and blood lakes

Tumor stain was obviously related to the

degree of vasculari ty of the tumor. In all of

the three cases, the staining of the tumor

could be seen f rom the early arterial phase

(Fig. 1B) to the late venous phase (Fig. 1C).

Marked vasculari ty and small blood lakes

could be seen in the tumor (Fig. 2A).

2. Arteriographic findings of the specimens

A. Supplying arteries

The branches of the supplying arteries of

the t h r ee c a s e s los t t h e i r n o r m a l

configuration when they enteryed into the

tumor region. In one case, the main supply-

ing ar tery of the tumor (inferior alveolar

artery) returned to normal configuration and

direction after it passed the tumor region

(Fig. 3). Under microscopic observation, we

found that the inferior alveolar ar tery lost its

Fig. 3 The case with fibrosarcoma of the mandibular molar region. Arteriograph of the specimen showed that the inferior alveolar artery lost its normal configuration when it entered into the tumor region and returned to normal configuration and dirction after it passed the tumor region ( ~ ).

1 2

normal configuration and become a dilated

pathological vessel with extremely thin ves-

sel walls in one case (Fig. 2B).

B. Distribution of tumorous vessels

Hypervascular i ty and vessel network

were present in all three cases. In the soft

mass of one case with osteosarcoma, we

found sunburst tumorous vessels which were

parallel to the sunburst tumorous bone.

Under microscopic observation, abundant

vessels with an ext remely thin vessel wall

between the sunburst tumorous bone could be

seen (Fig. 2C).

We also found that the highly vascular

areas correspond to the more malignant part

of the tumor and the areas of less vascularity

were less malignant.

C. Blood lakes

Different size blood lakes could be seen

in all three cases. Under the microscope, the

blood lakes showed as obviously enlarged and

sinus-like vessels with extremely thin vessel

walls only having one layer of endothe-

liocytes.

Discussion

1. Supplling arteries of the tumor

Angiographic studies on steosarcomas

and fibrosarcomas of long bones showed that

the supplying arteries of the tumors were

always from the arteries of the surrounding

soft tissues rather than from the nutrient

arteries of the bone. In the present study,

we found that the main supplying arteries in

two cases were f rom the inferior alveolar

artery, the main nutrient ar tery of the man-

dible, which was quite different f rom the long

bone sarcoma 6,r). Thus, the original nutrient

ar tery and the arterial network of the perios-

teal membrane play an important role in the

growth of the tumor. In the present cases,

we also found that the branches of the supply-

ing arteries of the tumor lost their normal

configuration and became irregularly narrow

and dilared when they entered into the tumor

region. These findings were consistent with

the findings in the osteosarcoma of long

bones% In addition, the present study

showed that the main supplying arteries of

the tumors were still form the original nutri-

ent arteries of the mandible, althogh the

tumor had penetrated through the cortical

bone of the mandible and entered into the

surrounding soft tissues. This was probably

due to the communication between the

peripheral branches of the inferior alveolar

ar tery and the vesel network of the periosteal

membrane.

2. Distribution of the tumorous arteries

In one case with osteosarcoma, we found

that sunburat tumorous vessels were parallel

to the sunburst tumorous bone. This is very

similar to the vessels of long bone osteosar-

coma described by Yaghmai% However, the

blood direction in this case was from. the

center to the periphery of the tumor rather

than from the periphery to the center of the

tumor. That was different f rom long bone

osteosarcoma%

3. Blood lakes and staining of the tumor

We found that the "blood lakes" showing

on arteriographs of the speciments were

actually highly enlarged pathological vessels

with an extremely thin wall. This kind of

pathological tumorous vessels was more

apparant in the more malignant areas. The

staining degree of different parts of the

tumor was different because of the quantita-

tive difference of this kind of vessels. We

also found that the contrast medium stayed

much longer in tumorous vessels than in the

normal vessels of the surrounding normal

tissues (Fig. 1B, C) perhaps because of obvi-

ous enlargement of the vessel caliber and

lack of elasticity of the vessel walls. There-

fore, this is a favorable condition for chemo-

therapy of local infusion by super selective

catheterization to the branches of the exter-

nal carotid artery.

Conclusions

1. The supplying arteries of the jaw sarcoma

could be from the main nutrient ar tery of the

jaw, which was quite different from the long

bone sarcoma;

2. The branches of the supplying arteries of

the tumor lost their normal configuration and

became irregular showing narrowing and

dilatation when they entered into the tumor

region;

3. The contrast medium stayed much longer

in tumorous vessels than in the normal ves-

sels of the surrouding normal tissues. Tha t

is a favorable condition for chemotherapy of

local infusion by super-selective ca the te r iza

tion to the branches of the external carotid

artery.

Aeknowledggment : The author wish to thank messrs

Sun, Guang-xi, Zhang, Yu-zhu, Wang, Chang-fu, Wu,

Dong, He, Ming, Guo, Zi-ming and Ms. Song, Xiao-xia for

taking the radiographs and their help in performing DSA.

References 1 ) Huvos, A. G.: Osteogenic sarcoma. Bone Tumors. ed 1,

pp. 47-93, A. G. Huvos, W. B. Sanders Company, Philadelphia

2) Lagergren, C and Lindborn A.: Angiography of

peripheral tumors. Radiology 79: 371-377, 1962

3 ) Hudson, T. et al.: The value of angiography in playing

surgical treatment of bone tumors. Radiology 138: 283-292, 1981

4 ) Lagergren, C. et 31.: The blood vessels of osteogenic sarcoma. Acta Radiol. 55: 161-176, 1961

5) Lagergren, C. et a1.: Vascularization of fibromatous and fibrosarcomatous tumors. Acta Radiol. 53: 1-16, 1960

6 ) Yaghmai, I.: Angiographic features of osteosarcoma.

A JR 129: 1073-1081, 1977

7) Yaghmai, I.: Angiographic features of fibrosarcomas.

Radiology 124: 57-64, 1977

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Reprint requests to: Xu-chen MA, D.D.S., Ph.D. Dept. of Oral Radiology, Stomatological Hospital, Beijing Medical University Haidian District, Beijing 100081, The People's Republic of China

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